title: Awake craniotomies without any sedation: the awake-awake-awake technique.
abstract: BACKGROUND
  Temporary anaesthesia or analgosedation used for awake craniotomies carry substantial risks like hemodynamic instabilities, airway obstruction, hypoventilation, nausea and vomiting, agitation, and interference with test performances. We tested the actual need for sedatives and opioids in 50 patients undergoing awake craniotomy for brain tumour resection in eloquent or motoric brain areas when cranial nerve blocks, permanent presence of a contact person, and therapeutic communication are provided.
  
  
  METHODS
  Therapeutic communication was based on the assumption that patients in such an extreme medical situation enter a natural trance-like state with elevated suggestibility. The anaesthesiologist acted as a continuous guide, using a strong rapport, nonverbal communication, hypnotic suggestions, such as dissociation to a "safe place", and the reframing of disturbing noises, while simultaneously avoiding negative suggestions. Analgesics or sedatives were at hand according to the principle "as much as necessary, but not more than needed".
  
  
  RESULTS
  No sedation was necessary for any of the patients besides for the treatment of seizures. Only two-thirds of the patients requested remifentanil, with a mean dosage of 96 μg before the end of tumour resection and a total of 156 μg. Hemodynamic reactions indicative of stress were mainly seen during nerve blockades and neurological testing. Postoperative vigilance tests showed equal or higher scores than preoperative tests.
  
  
  CONCLUSIONS
  The main challenges for patients undergoing awake craniotomies include anxiety and fears, terrifying noises and surroundings, immobility, loss of control, and the feeling of helplessness and being left alone. In such situations, psychological support might be more helpful than the pharmacological approach. With adequate therapeutic communication, patients do not require any sedation and no or only low-dose opioid treatment during awake craniotomies, leaving patients fully awake and competent during the entire surgical procedure without stress. This approach can be termed "awake-awake-awake-technique".
authors.affiliation: Department of Anaesthesiology, University Hospital Regensburg, 93042 Regensburg, Germany. ernil.hansen@ukr.de
authors.forename: Ernil
authors.initials: E
authors.lastname: Hansen
authors.forename: Milena
authors.initials: M
authors.lastname: Seemann
authors.forename: Nina
authors.initials: N
authors.lastname: Zech
authors.forename: Christian
authors.initials: C
authors.lastname: Doenitz
authors.forename: Ralf
authors.initials: R
authors.lastname: Luerding
authors.forename: Alexander
authors.initials: A
authors.lastname: Brawanski
mesh_terms: D000772:Anesthesia, Local / Q000379:methods; D001931:Brain Mapping / Q000379:methods; D001932:Brain Neoplasms / Q000473:pathology / Q000601:surgery*; D003399:Craniotomy / Q000379:methods; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives; D007431:Intraoperative Complications / Q000517:prevention & control; D008297:Male; D019635:Neurosurgical Procedures / Q000379:methods; D014851:Wakefulness / Q000502:physiology*
chemical_list: D006993:Hypnotics and Sedatives